Mastectomy for Breast Cancer

Overview
Mastectomy is surgery intended to remove all breast tissue. It is used as treatment for breast cancer or as prevention for women who are at especially high risk for developing breast cancer. Mastectomy to remove one breast is referred to as unilateral mastectomy; if both breasts are removed, it is referred to as bilateral mastectomy. In a total or simple mastectomy, all breast tissue and the nipple are removed. In a modified radical mastectomy, most of the lymph nodes under the arm, the lining over the chest muscles, and part of the chest wall may also be removed. For women who choose to have reconstructive surgery immediately after mastectomy, the surgeon may use skin-sparing or nipple-sparing (also called subcutaneous) techniques, if appropriate.

Mastectomy is a treatment option for various types of cancer including early (stages 1 and 2) breast cancer; locally advanced (stage 3) breast cancer; cancer that recurs in the same breast after lumpectomy; inflammatory breast cancer; Paget’s disease of the breast; and ductal carcinoma in situ, also known as DCIS or noninvasive breast cancer.

Mastectomy may also be recommended for women in certain medical situations, especially those in which adjuvant (after surgery) radiation therapy may not be possible. Pregnant women, women who have already had a course of radiation to the same breast, or women with other conditions such as lupus, scleroderma, or vasculitis that make the side effects of radiation harder to tolerate may be candidates for mastectomy. Mastectomy may also be advisable in cases where tumors are extensive in the breast; where there are tumors in more than one area in the breast; if a previous lumpectomy has failed to remove the tumor; or if a woman has small breasts and a large tumor, which could make the scars more disfiguring. Your doctor may also recommend mastectomy if you carry a genetic mutation that raises your chances of recurrent breast cancer.

Even if you have a mastectomy instead of a lumpectomy, your doctor may advise that you have adjuvant radiation therapy. Radiation therapy may be especially advisable after mastectomy in cases where a tumor was larger than five centimeters; if cancer cells are found in one or more lymph nodes; where the surgeon could not create a clear margin of healthy tissue around the tumor that was removed; or where there were tumors in multiple locations.

What does it involve?
In order to decide what type of surgery is best for you, you will meet with a surgeon and an anesthesiologist. Together you will review your medical history, discuss the benefits and risks of each type of surgery, and develop a plan for surgery and anesthesia. You can also decide at this time whether you want to receive reconstructive surgery immediately after your mastectomy procedure, while you are still under anesthesia. Do not be afraid to ask questions and make sure you understand each option. Find out how long you can expect to be in the hospital so that you can pack accordingly.

Starting at least one week before your mastectomy is scheduled, your surgeon will ask you to avoid pain-relievers such as aspirin or ibuprofen or anticoagulant medications such as Coumadin. These drugs thin your blood and can promote excess bleeding during surgery. Your surgeon will also ask you to stop eating or drinking eight to 12 hours before surgery is scheduled to begin.
Mastectomy is performed under general anesthetic. A unilateral mastectomy usually takes one to three hours. Bilateral mastectomy and reconstructive surgery require additional time. Most mastectomy incisions are in the shape of an oval around the nipple and areola, from one side of the breast to the other. If your surgeon is using a skin-sparing technique, the incision will be smaller, confined to the nipple and areola. At the end of the surgery, the surgeon will insert one or two temporary rubber drainage tubes to drain excess fluid from the wound. Drainage tubes may be removed before you leave the hospital, or within one to two weeks after your surgery. Once the drainage tubes are placed, the surgeon will close the wound with stitches or staples.

After mastectomy surgery, you will be sent to a recovery room. During this time, your blood pressure, heart rate and temperature will be monitored. If you feel nauseous from the anesthetic, let the hospital staff know so they can give you medication for this. Most women stay in the hospital for one or two days afterward, although some go home the same day the surgery is performed. Before you are discharged, your surgeon will provide instructions on how to care for your wound and drainage tube or tubes, how to exercise your arm so it does not become stiff, and how to recognize signs of infection. They will also tell you which activities you should restrict while you recover, and when you can begin wearing a bra or breast prosthesis. You will be given a prescription for pain medication and possibly an antibiotic. Make sure you understand the instructions, and do not be afraid to ask questions.

While you finish your recovery at home, get plenty of rest. Take pain medications as needed. Carefully monitor your wound for signs of complications. Call your doctor immediately if you experience swelling or redness in the arm or hand on the side you had the mastectomy. Avoid showers and baths and take sponge baths until your doctor has said you can resume your regular bathing routine.

The tissue removed during the mastectomy will be sent to the lab for testing. It may take one or two weeks to receive results. Depending on the lab results, your doctor may recommend radiation therapy, chemotherapy[LINK] or specific hormone drugs like Tamoxifen[LINK] or targeted therapies such as Trastuzumab[LINK].

Intended Outcomes
Mastectomy can remove tumors and help prevent the recurrence or spread of breast cancer. In women with especially high risk for developing breast cancer, mastectomy can help prevent the disease.

Results
In a summary of clinical trials involving at least 150 participants and with at least 10 years of follow-up, mastectomy was found to be equivalent in effectiveness to lumpectomy with radiation at treating early breast cancer in terms of overall survival. The summary was updated in January 2014.

In a summary of clinical trials involving at least 1,000 participants and with at least 10 years of follow-up, radiation therapy after mastectomy was found to substantially increase chances for survival. The summary was updated in January 2014.

The results of a clinical study published in 2010 indicated that preventative mastectomy reduced the risks of developing breast cancer among women with BRCA1 or BRCA2 genetic mutation. The study followed 2,482 women for three years. Among those who received preventative mastectomies, none developed breast cancer. Among the women who were positive for the genetic mutation but did not receive mastectomies, seven percent developed breast cancer during the period of the study. Only five to 10 percent of breast cancers involve a genetic mutation.

Constraints
You may have numbness, tenderness, pain or extra sensitivity in the area around the mastectomy incision. While some of these sensations may improve as your nerves regrow, some numbness may be permanent.

Your mastectomy scars may be hard, bumpy or painful. There are ways to manage these problems.

There may be swelling in your arm on the same side as your mastectomy. This is known as lymphedema. Contact your doctor if this occurs.

After any surgery, there is increased risk for infection at the surgical site. While your mastectomy wound is healing, monitor the incision for swelling, redness, pain or heat. If you suspect infection, contact your doctor right away. Infections that are caught early should be easily managed with medications.

Fluid may collect beneath your scar after mastectomy. This is called hematoma or seroma. If this occurs, your surgeon will drain it with a needle.

You may experience shoulder pain or stiffness on the same side as your mastectomy.

If you are taking certain medications or do not get enough of certain nutrients, you may experience delayed wound healing. This is a rare complication of mastectomy. If you feel that your mastectomy wound is not healing properly, speak with your doctor right away.

Any type of surgery carries risks including blood clots, blood loss, infection, breathing problems, reactions to medication, and heart attack or stroke during the surgery.